Low vision: we can all do more

Use real tasks to assess near vision. TANZANIA Despite all the treatments, operations, and medication at our disposal, there is still a significant number of people whose sight we cannot fully restore. What happens to these patients once they leave our care? Without the necessary support, advice, and low vision devices, their remaining vision will not be very good; this can make life a struggle. Support may be difficult to find, as low vision services are often inadequate or inaccessible in many lowand middleincome countries. Professionals, such as rehabilitation workers, ophthalmologists, mid-level eye care workers, optometrists/ refractionists, and special education teachers, may not know what to do about people with low vision, leaving them with no-one else to turn to. Individuals who can only see light or movement of large objects will need rehabilitation that focuses on non-visual strategies for learning and daily tasks. However, there are many people who have slightly better vision, but are still classified as blind, who have the potential to use their sight. These people could benefit from low vision care, which may include refraction, provision of magnifiers, and/or environmental modifications. The World Health Organization defines a person who needs to be assessed for low vision care as someone “who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 down to and including light perception, or a visual field of less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of task.” The important part of this definition is that people should only be assessed for low vision interventions once all other treatments the person needs (surgical, medical and/or optical) have been given. The definition also emphasises the importance of vision for day-to-day functioning. People who may be able to benefit from low vision care will want to do a range of different things. In many lowand middleincome countries, for example, many people with low vision are aged over 50 years and cannot read or write. They will have different needs, and require different services, compared to children or adults in employment. Low vision has a significant impact on people’s lives. People with low vision may struggle to look after themselves without help. Having low vision affects their status in the eyes of others and can make social situations difficult. It reduces the ability of people to pursue an education, to look after their children, and to earn an income. People with low vision are also at greater risk of falls and death. With our support, people with low vision can make better use of their sight to do the things they want and need to do. We hope this issue will show you how.

Despite all the treatments, operations, and medication at our disposal, there is still a significant number of people whose sight we cannot fully restore.
What happens to these patients once they leave our care? Without the necessary support, advice, and low vision devices, their remaining vision will not be very good; this can make life a struggle. Support may be difficult to find, as low vision services are often inadequate or inaccessible in many low-and middleincome countries. Professionals, such as rehabilitation workers, ophthalmologists, mid-level eye care workers, optometrists/ refractionists, and special education teachers, may not know what to do about people with low vision, leaving them with no-one else to turn to.
Individuals who can only see light or movement of large objects will need rehabilitation that focuses on non-visual strategies for learning and daily tasks. However, there are many people who have slightly better vision, but are still classified as blind, who have the potential to use their sight. These people could benefit from low vision care, which may include refraction, provision of magnifiers, and/or environmental modifications.
The World Health Organization defines a person who needs to be assessed for low vision care as someone "who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 down to and including light perception, or a visual field of less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of task." The important part of this definition is that people should only be assessed for low vision interventions once all other treatments the person needs (surgical, medical and/or optical) have been given. The definition also emphasises the importance of vision for day-to-day functioning.
People who may be able to benefit from low vision care will want to do a range of different things. In many low-and middleincome countries, for example, many people with low vision are aged over 50 years and cannot read or write. They will have different needs, and require different services, compared to children or adults in employment.
Low vision has a significant impact on people's lives. People with low vision may struggle to look after themselves without help. Having low vision affects their status in the eyes of others and can make social situations difficult. It reduces the ability of people to pursue an education, to look after their children, and to earn an income. People with low vision are also at greater risk of falls and death.
With our support, people with low vision can make better use of their sight to do the things they want and need to do. We hope this issue will show you how.
• All children who have undergone bilateral cataract operations, both those with pseudophakia and those with aphakia • People with diabetic macular oedema whose vision remains poor despite laser treatment • People with age-related macular degeneration • Children with oculocutaneous albinism • People with optic atrophy, whatever the cause • Any person who still has difficulty performing their daily activities because of their vision, even after treatment and refraction.

What does low vision look like?
People with low vision are affected in different ways. They may suffer from some or all of the following: • Severely reduced visual acuity • Blurred vision • Visual field loss: central or peripheral • Loss of contrast sensitivity • Increased light sensitivity.
Many people with low vision suffer from blurred vision (Figure 1), for example if they have scarring on their corneas. People with optic atrophy or age-related macular degeneration will have loss of central visual acuity (Figure 2), which means that tasks requiring good central vision will be difficult. For example, reading, writing, threading a needle and sewing, putting on make-up, recognising people, seeing where their food is on the plate and whether they have finished eating, seeing if their clothes are clean, finding their own pair of shoes. If they have a full field of peripheral vision then mobility will be less of a problem.
Someone with glaucoma or retinitis pigmentosa will have constricted visual fields, i.e. loss of peripheral vision (Figure 3). This makes it difficult to move around without bumping into objects on the floor. People may have difficulty finding things they have dropped. Reading may still be possible, but difficult.
Loss of contrast sensitivity (Figure 4) can have a very big impact on someone's visual function, making it difficult to recognise faces or find food on a plate of similar colour.
Increased light sensitivity makes it very difficult for people to see detail or make sense of what they see if they are in bright light, or glare ( Figure 5).

Understanding low vision
Clare Gilbert Co-director, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Clinical Advisor, Sightsavers.      India has an estimated 280,000 blind children, which is one of the highest in the world. According to different studies (1) the prevalence of childhood blindness in India varies from 0.62 to 1.06 per 1000 children in 0 -15 age group as also the causes of blindness. Earlier studies in India attributed corneal scars as the leading cause of blindness in the country (8). However, subsequent studies found reduction in corneal blindness and globe abnormalities emerging as the major cause. In a study done in the north eastern states of India, congenital globe abnormalities was found to be the commonest cause (36%) of blindness among children (2). And according to Andhra Pradesh Eye Diseases Study (APEDS), treatable refractive error caused 33.3% of the blindness, followed by congenital eye anomalies (16.7%) (3).

Comprehensive low vision services in West Bengal
It is unfortunate that such a large number of children are suffering from visual impairment and blindness but the mechanism of finding them and organising service for them is a challenge. Different approaches have been tried to find such children: examining children in special schools, ICDS (Integrated Child Development Services), school screenings are the usual ones in India.
This article depicts the experience of working with the special educator workforce and scaling up the same in a large population.
Sarva Shiksha Abhiyan ( SSA) (Education for All Movement) is a programme by the Government of India aimed at universalisation of elementary education as mandated in the 86th amendment of the Constitution of India making free education for children aged 6-14 a Fundamental Right. SSA is being implemented in partnership with state governments throughout the country. This is an inclusive method of education for all differently able children and visually challenged children constitute a major bulk. Earlier, specialised education used to be imparted to these children through schools for the blind. But now inclusive education has evolved as the most practical way of educating visually impaired children. In fact, the concept of inclusive education developed because institutional education had some serious drawbacks: Number of institutions was inadequate for the total number of persons who needed them.
• Establishment and maintenance of institutions was expensive. • Individuals studying were detached from their families and society. • Social and vocational adjustment became difficult when the individual returned to the community after training. • Institutional education in many occasions failed to involve the communities where people with disabilities come from. According to 2011 census, the state of West Bengal has a population of 91,347,736 contributing to 7.55% of India's population. The State has 19 districts with a population density of 1029 per sq. km. Population in 0 to 6 age group is 11.07%, decadal growth rate is 13.93% and literacy rate is 77% (82% male, 71% female). (7) During the year 2009-11, Sarva Siksha Mission, West Bengal took up a large scale project of identifying children with visual impairment and to help them through provision of low vision devices and corrective surgeries. Two organisations having the capacity of providing low vision services were allotted ten educational districts each for this extensive work. Our organisation was one of them and worked among half of the State's population.
During these two years -2009 -11, 10900 children (6174 (57%) boys and 4726 (43%) girls) were examined in ten districts by our team. Out of them, 3814 children were prescribed low vision devices and 3669 received the required aids. Nine hundred and ninety three students were selected for cataract and other surgeries and from among them, surgeries were performed for 605 children.
For a better understanding of the epidemiological issues related to childhood blindness, we are showcasing our experience in one remote district of West Bengal that borders Bangladesh and Assam. This study depicts our experience in Cooch Behar, an economically underdeveloped district with a population of about 2.5 million with a decadal growth rate of 13.86 and literacy rate of 75% (7).

Asim Kumar Sil
Earlier study reports on childhood blindness in India were based mainly on schools for the blind; very few of them were community based. This experience is unique as it looks at the pattern of blindness amongst children identified through SSA and more importantly, the service need for them.

Target Beneficiaries:
All children below 16 years of age as per UNICEF definition of childhood were included. There were a few students above 16 years. All children with functional low vision were examined.
According to a World Health Organisation (WHO) consultant, a person with low vision is one who has impairment of visual function even after treatment or refractive correction and has visual acuity of less than 6/18 to perception of light or visual field of less than 10° in the better eye, who uses or is potentially able to use vision for planning or execution of a task (5).

Process:
Following a two day training programme at base hospital, the special educators identified children with visual impairment. Visual Acuity (VA) was assessed in each eye by using a Snellen's tumbling "E" visual acuity test chart. All the identified children were brought to the Block level Circle Office by the special educators.
In each of the low vision camps, a team of four optometrists did a detailed examination of around 40-45 visually impaired children. A brief demographic detail, medical and family history of each child was recorded. VA was recorded using LogMAR chart. For the uncooperative child, VA was assessed by the ability to fix and follow light. Near vision was assessed using figures equivalent to N. The visual status of children was recorded using WHO categories of visual impairment before and after refraction. Optometrists then referred the children to ophthalmologist for a final diagnosis and treatment plan The ophthalmologists from our organisation carried out a detailed eye examination of each child at SSM district head quarters. Those who needed surgical intervention were referred to the base hospital.
At the base hospital, children above eight years were operated under local anesthesia, while younger children, and those who were mentally challenged, were administered general anaesthesia. For cataract cases, Intra ocular lens implantation with Primary Posterior Capsulorhexis (PPC) was done to prevent posterior capsular opaci-fication. As the children were from far off places, PPC was done in all cases, since we felt that these underprivileged children will not be able to come for a regular follow up. Other common surgeries were surgical capsulotomy, pupilloplasty, optical iridectomy, ptosis correction (blepharophimosis syndrome constituted a major bulk) and squint correction.
A low vision device distribution ceremony was organised at a central location to create general awareness and also to encourage interaction among the parents of low vision children. Policymakers, politicians and senior government officials attended the function and interacted with children.

Follow up:
Follow up has been conducted for all the operated cases after a period of one and six months at the district head quarters both by optometrists and doctors. A follow up meeting was conducted with the special educators to get their feedback about the use of devices. Data of all the children were analysed using WHO prevention of childhood blindness database.
Profile of low vision and blindness among children examined during the project in Cooch Behar district:

Discussion:
Reports of earlier studies on childhood blindness are mainly blind school based and there are some biases inherent in any study of children in schools for the blind. There is always a likelihood that children with multiple disabilities, pre -school aged children, those from lower socioeconomic groups and from rural communities are underrepresented in schools for the blind. The service delivery needs of the community could not be assessed through this study. This study shows the importance of low vision intervention at grass root level.
A significant proportion (about 50%) of children achieved N8 or better which is a is readable vision. However rest of the students could not gain good vision due to dense amblyopia, retinal inability and media opacity. Those with gross low vision and progressive disease were advised to get trained in Braille.
Cooch Behar is one of the backward districts in West Bengal with a poor economy and law and order problems.
Still a good response was received from all the stakeholders. Thirty eight special educators were successful in bringing 453 children for examination overcoming all the hurdles of communication. Children screened by teachers had high false positives but needy children were not missed out.
This project has helped many children access to normal print. Previously they were either reading via Braille system or only listening to their teachers. Early introduction of low vision devices will make these visually impaired children more confident, and they will be able to compete with their peers who have sight. Sarva Siksha has successfully included several children in the mainstream education. Still many more are left out but there is no information available about their visual status.
Most significant aspect of this project was the successful advocacy with the government and receiving encouraging support from them. In a positive move they have decided to continue the project. Another success was developing continuous relationship with the teachers and parents. Special educators are more sensitised about the need of visually challenged children because of their trained background. Their activities are also more focused towards the welfare of their students. This was evident in their involvement in the whole process. Based on their feedback from previous years, training curriculum was effectively modified.

Conclusion and recommendation:
This project is a good example of a comprehensive approach of reaching children in large scale and providing them service with equity and also helping in designing Individual Education Plan (IEP) for the class VI students. This is the first such type of project conducted in India. Other state governments have shown interest towards this project. Our recommendation is to incorporate this project in the National Programme for Control of Blindness in India. The department adopted various strategies to reach all those who need low vision care. In the hospital a protocol is adopted that no person will go without visiting low vision department if that person is in the low vision category. This is communicated to all the ophthalmologists and they are made aware about the available services and its impact on individual's life.

References
In order to reach the children who are not able to access services in the hospital, the hospital sends its team of experts to outreach camps held under Sarva Shiksha Abhiyan for distribution of disability certificates to the screened children. Various studies conducted in schools for the blind across India have shown that many children can be benefitted by provision of low vision aids so the hospital conducted regular assessment of these children for low vision and provideds them with appropriate devices.
In order to increase the acceptance of services by more ophthalmologists so that they will refer their patients to the hospital low vision experts need to create awareness amongst them by providing them with data so the hospital conducted research in impact assessment of provision low vision care in pediatric and adult population and disseminates the results by presentations and publications on regular basis.
These initiatives have led to screening more than 1000 adults and 700 paediatric patients in last three years. We hope that these experiences of people with low vision will highlight what is important in a low vision service.

Before
Before they received low vision care, the adults said they had been unable to do their desired activities, such as driving or reading. They were worried about their vision and had negative feelings, including stress, depression, anger, and frustration. They had also felt dependent on their family, and that they were a burden to the family. The adults had also struggled to accept their condition as being irreversible.
School-age children and young adults said that they had been unable to attend school, had to drop out, or had faced great difficulties in their schooling, such as being unable to take examinations. Some of them had been treated as blind and taught to use Braille.
These young people had also felt very dependent on their families and had to stay home much of the time.
One of the biggest problems they had faced was the way society viewed them. They were victims of bullying, namecalling, and had been accused of pretending to have a problem.

Care provided
The care provided to both children and adults consisted of training in better use of vision, provision of optical devices, and suggestion of environmental modifications. Specific interventions included: • Changes such as sitting near the window or using a lamp, sitting near the blackboard, using a stand for better reading/writing position and more comfort, increasing contrast through better light, using a reading slit, and using a cap to reduce glare out of doors • Giving advice about improving the environment through painting lines or applying tape to improve contrast • Someone taking the time to clearly explain the person's eye problem and prognosis to him or her • Counselling, particularly for adults who were able to see before and have lost a lot of their vision. This involved listening, discussing the implications of the vision loss and the effect on their life and emotions, and giving advice if needed.

Impact
Adults described how low vision services had resulted in the following: • Greater independence, confidence, courage, hope, and dignity • A better understanding of the reality of the visual loss.
Children talked about how the low vision service had helped them with the following: • Starting school • Doing desired activities, such as reading print, even small print • Increased independence, for example being able to read the blackboard and learning to write • Improving the attitudes of peers and teachers "… who now see I can do many things." • Better social interaction, for example "… recognising the faces of my friends." What more is needed?
• Some people still lacked the confidence to use their optical devices in public • Most people also wanted to be informed if there were new technological developments, and hoped for lower prices for software and electronic low vision devices • Some children did not know enough about their condition and wanted someone to explain it to them in terms they could understand.
In our experience, it is helpful to keep in touch with people who have been helped by low vision services. They can be excellent advocates for the development of better services and may help to convince others with low vision to seek help. Children who successfully use a low vision device can also inspire other children who are still struggling.
The interviews were arranged, transcribed, and translated by: As clinicians, being faced with a patient whose vision we cannot improve any further can make us feel like a failure. However, there are many ways to help such a person with low vision. Figure 1 shows the difficulties someone is likely to have, based on their distance visual acuity, and what support they may be able to benefit from. These include optical devices, non-optical devices, advice on environmental modifications, and referral to rehabilitation and (special) educational services.
In this article, we will show you how to assess a person with low vision and find out what it is they really want to be able to do. We will then outline the interventions that are possible, and give some guidelines.

Before you start
When you are faced with a person with poor vision, it is important to check that everything possible has been done to improve their vision, and that they really do need low vision services. Here is a checklist: 1 Has the person's diagnosis been confirmed by an ophthalmologist or other eye care worker?
2 Has all the medical, surgical, and optical treatment possible already been given? 3 Has the prognosis for vision been confirmed by a medical professional? If the answer to any of these questions is 'no', refer the person to the appropriate services, where possible.
If we know the diagnosis, this will give us some idea of the likely impact on the person's visual function and thus on their main visual needs (see page 2).
Ideally, people with low vision should have undergone refraction, and be wearing their spectacles, before they are given low vision support. In practice, many eye care practitioners find it too challenging and/or time-consuming to refract someone with low vision. This is why refraction should always form part of a standard low vision assessment.
Once you have established that the person does need low vision services, you can begin the low vision assessment.
The following are the steps that normally form part of a low vision assessment: • Taking  This is an important part of the low vision assessment and provides an opportunity for you and the patient to get to know each other.
Encourage the patient to talk about their problems. Asking open-ended questions will help; these are questions starting with words such as 'when', 'what', 'how', and 'where' -questions which don't have 'yes' or 'no' as an answer.
Ask questions about: • Their own eye health -how their vision is affected, what makes it worse or better and how it has changed over time • Their general medical history, their mobility, and their medications • Their family's eye health history • Their occupation and hobbies • Any previous low vision assessments.
Here are examples of questions you can ask about their eye health and vision: • When did you first notice a problem with your vision? • What kinds of problems have you noticed?
• What problems do you have in the day?
• What problems do you have at night?
• What changes, if any, have you noticed in your vision? • What makes your vision worse?
• What makes your vision better?
Explaining the eye condition Some people with low vision will not have had their eye condition explained to them, or they may not have understood the explanation at the time.
It is always worthwhile taking time to explain the eye condition again, in terms the person can understand. Even if patients with low vision have heard it all before, they will probably find it reassuring to have you explain it again, thereby confirming what they have heard from others.
Be positive. Emphasise that they have some residual vision and that you and your colleagues are committed to helping them make the most of that vision. Reassure them that they cannot harm their residual vision by using it -they will not 'wear out' their eyes! determining the patient's needs Start on a positive note by first asking what they can still do, before going on to ask what they may be struggling with.
Ask about their mobility, activities, and participation. Here are some examples. • Regaining the ability to read their personal correspondence • Helping to cook again instead of just sitting around • Learning to identify the correct medication and taking it independently • Making a visit to a neighbour on their own, whenever they feel like it.

Mobility
When discussing these topics, think about the following: • Do they need help with near and intermediate vision, with distance vision, or with all distances? • Is the task long (reading) or short (looking at the oven temperature dial)? • Do they need to have one or both hands free? • What other visual functions might be affected and must be assessed?

accurate refraction
The importance of good refraction in a low vision assessment cannot be overstated.
Refracting people with low vision differs from refracting people whose vision can be improved to normal (6/6 or 20/20), as the person with low vision is less sensitive to small changes in the a 60-year old retired professor with age-related macular degeneration complained that he could no longer read small text, which had been an important part of his life. He also taught college students and worked extensively on the computer at home. On further questioning, it became clear that he also had difficulties in communicating with others. From the history, interview, and diagnosis, we knew that the man had central field loss and reduced contrast sensitivity, which would require improved lighting and contrast.
The low vision team assessed his best corrected distance and near visual acuity, contrast sensitivity, reading and writing ability, and the extent of his field loss.
His visual acuity, tested on a logMAR chart, was 6/36 (0.8 logMAR) in the better eye, and with a +2.00D add his near vision was 1M (N8) at 15 cm. His near acuity improved to 0.63M at 25 cm with an add of +3.00D, a reading lamp, and a reading slit. With these, he was also able to read the newspaper and his writing was legible.
The professor was advised to wear his bifocal glasses constantly, to read with a table lamp and reading slit, and to use a reading stand. A signature guide helped him to sign cheques.
He was taught how to use eccentric viewing (see page 8), which helped him to recognise people more easily. This helped him socially.
The professor was advised about the importance of explaining to his friends and family why he was not able to make direct eye contact.
He was also directed to the local government office to obtain a disability certificate and other paperwork. power of trial lenses and may respond much more slowly. Patience is essential, and using the bracketing technique (see panel) can help.
Fatigue and frustration can negatively influence the outcome of the refraction. Ensure the person is seated comfortably and give them time to recover from any signs of stress or tiredness.
While doing refraction, the test chart should be at a distance where the patient can see at least the top line of letters. Full aperture trial lenses should be used to allow the patient to move their head or eyes in order to fixate eccentrically (see panel on page 8).
Assess the near addition (lens) needed and measure the working distance with which the patient is comfortable. Record their best corrected near and distance visual acuity.

assessing residual vision
The support we provide depends on having a thorough understanding of the person's overall visual function. For example, people with poor contrast sensitivity may require more magnification than suggested by their near visual acuity alone.
When assessing someone with low vision we therefore need to have a better idea of their overall visual function, including: • Distance visual acuity • Near visual acuity • Contrast sensitivity • Visual fields • Light sensitivity • Colour vision If you work in a setting with limited resources, the improvement of distance and near visual acuity can be emphasised; the other visual functions can be tested functionally, as suggested here.
If you work at a large eye hospital, use the appropriate tests and equipment.

distance visual acuity
We are used to testing distance visual acuity using standard Snellen charts at only two distances: six metres (20 feet) or three metres. However, when testing someone with low vision, we should preferably use logMAR charts as they give better measures of acuity. If the person cannot see the letters at three metres, we must also test at other test distances, such as two metres, one metre, etc.
near visual acuity It is very important to test everyone's near vision, not just those who can read and write, as good near vision is needed for a very wide range of other activities. We must also know the near visual acuity so that we can prescribe low vision magnifiers for near tasks, if needed.
Near visual acuity can be tested using logMAR charts ( Figure 2) similar to those used for testing distance visual acuity. It is important that comparable tests for both are used. The choice of test depends on age, development level, and literacy of the client, e.g., tumbling Es or Landolt rings.
It may be useful to assess near vision at a distance of 25 cm (see article on page 9). Note that people with presbyopia may need an appropriate addition in order to read at this distance. In addition to near vision, reading and writing performance should be assessed among those who are literate. This is because reading requires other functions that are not assessed in acuity testing, for example, locating the next line of print. If near acuity only is measured, difficulties with reading may be missed.
The best way to assess reading is to use printed text from a newspaper or book and to ask the person to read it aloud. Reading aloud allows the assessor to hear mistakes and observe the person's

ManaGInG LOW VISIOn Continued
Because patients with poor visual acuity may have difficulty in determining small changes in lens power and clarity, it is often necessary to make large power changes.
A bracketing technique can be useful. For example, use a +2.00DS trial lens and compare this with a −2.00DS trial lens. If the patient is able to differentiate between the two, the lens giving the better vision can be added and the technique repeated using, say, a +1.00DS and a −1.00DS lens, etc. It may be necessary to refract the patient with the chart placed at 3 m or less. If this is done, the result is over-plussed (the chart at 3 m acts as a near object and therefore adds a vergence of about −0.30D in the plane of the trial lens) and a correction should be made according to the test distance. year-old man with glaucoma, who drove himself to work in a factory, was referred to the low vision clinic. He was married with two school-age children, and was the main breadwinner in the family.
The man said that he had problems with driving and working in the evenings, and had difficulty navigating inside the factory. These difficulties were the result of loss of peripheral field and reduced contrast sensitivity related to the glaucoma. He also had difficulty in crossing roads, identifying curb edges, walking in shaded places, and identifying landmarks. These findings suggested a need for better illumination in the evenings and in situations of poor lighting.
The low vision assessment included distance and near visual acuity with best correction, visual field testing by confrontation, and contrast sensitivity testing using light-coloured objects against a dark background. Mobility was tested in different lighting conditions by going for a short walk with the client. His distance visual acuity was 6/24 (0.60 logMAR) with his myopic glasses of -4.00D. He could read 1M (N8) without his glasses at 20 cm.
A 6D hand-held magnifier was prescribed to make reading the newspaper and small print on the machinery more comfortable, and he was advised to wear a cap with a visor to reduce glare when in bright sunlight. After consultation with his employer, levels of illumination in the factory were increased. This improved contrast, enabling him to navigate doorways and concrete pillars more easily. This improved his mobility, working efficiency and confidence. He was advised to travel to work using public transport or share rides with co-workers. The need for regular review and continued use of glaucoma medication was explained. Continues overleaf ä visual skills. Contrast sensitivity Contrast sensitivity is the measure of the eye's ability to detect differences in greyness and background, or small changes in brightness. Most of our world is in moderate to poor contrast. Visual acuity charts are one of the few things in high contrast! Reduced contrast sensitivity can be assessed functionally by asking questions such as: • Do you find it more difficult to walk around in very bright sunlight, or at dawn and dusk? • Can you see the white light switch on the light-coloured wall in your house? • Can you read your bills (which are often on grayish paper, with poor contrast)?
There are several ways of testing contrast sensitivity clinically, such as the Pelli Robson chart, but these charts are expensive and require that the person with low vision is literate. A less expensive alternative is the Lea low-contrast flip chart (see page 13 for ordering details), which is suitable for those who are not literate, including children. Low contrast may explain why a person with a visual acuity of 6/36 can manage many tasks well, but struggles in poor light.
Contrast: tips for daily activities It is not easy to translate these findings to impact on daily activities. In general, moderate contrast sensitivity might have an impact on reading, whereas very poor contrast sensitivity might indicate the need for visual rehabilitation and mobility training. You can help people with low contrast sensitivity by advising them how to increase contrast in their environment. There are two main ways: 1 use better lighting. For example, sit by the window to read or sew, or use a lamp. Be aware: very bright light, including direct sunlight, can reduce contrast. 2 make adaptations in the environment.
For example, use paint or coloured tape to create contrasting strips on steps or around light switches.

Light sensitivity
Both too little light, and too much light (glare), can affect what someone with low vision is able to see. People with increased light sensitivity struggle to see in the presence of bright light (for example, light reflected by a shiny blackboard or table top). This is a common problem for people with low vision.
In the presence of such bright light, or glare, contrast is reduced and recognising objects or people can become very difficult. People with reduced light sensitivity also struggle to see, and will often also have reduced contrast sensitivity.
Light: tips for daily activities Getting the amount of light right is the key intervention in this situation. Ask what the person is struggling with, such as seeing at night (reduced light sensitivity) or seeing outside in bright sunlight or when the light reflects off the blackboard (increased light sensitivity).
For people with reduced light sensitivity, recommend that they sit near a window or try different lamps.
You can determine the best lighting conditions for particular tasks, such as reading or sewing, by letting the person try out different types of lamps in the clinic.
People with increased light sensitivity could wear tinted glasses, sunglasses, or a cap outdoors to help with glare. Filters ( Figure 3) can help people with both contrast and/or light sensitivity by minimising glare and increasing contrast. Filters look like safety glasses and are available at low cost (see page 13 for ordering details). Many different colours and shades are available, such as yellow, brown, grey, red, etc.
People may need two different shades of a particular filter: one for indoor use (light) and one for outdoor use (dark).

Visual fields
Ideally, the clinician making the diagnosis will have assessed the patient's visual fields as part of their clinical assessment. If not, questions can help.
Patients may realise that they cannot see detail clearly but can see well enough to walk around. This suggests central visual field loss; this is often due to macular degeneration.
Someone with peripheral field loss from glaucoma or retinitis pigmentosa can see detail but will bump into furniture or fall over things on the floor.
There are a range of tests available, including confrontation (face-to-face) testing, static tests (e.g. Friedmann visual field analyser), and dynamic tests (e.g. tangent screen or Goldmann tests).
The Amsler grid test is used to plot d iabetic retinopathy made a 75-year-old woman unsure of her bearings at home, even though she had undergone cataract surgery with intra-ocular lens implantation. She was unable to identify different utensils and other items, such as spices, in the kitchen. She also could not see the knobs on the gas cooker. She was keen to do her own cooking, gardening, reading, and shopping.
Pseudophakia is accompanied by loss of accommodation, while diabetic retinopathy can result in sensitivity to light, patchy field loss, with reduced contrast sensitivity and color discrimination.
These visual functions were all assessed. Her best corrected distance visual acuity was 6/60 (1.0 logMAR) with astigmatic correction.
With a near add of +4.00D, she could read 1.6M at 20 cm.
The interventions recommended focused on improving her near visual acuity and included an 8 dioptre illuminated stand magnifier, which enabled her to read 1M print, using a reading stand to help her read more comfortably. She could also use the magnifier to identify money.
She was trained in the use of eccentric viewing to assist in daily activities and was shown how to fold paper money in different ways so she could tell which amount they were for.
To help in the kitchen she was advised to use different coloured labels for different pots and to use containers of varying shapes or sizes for her spices. She was also advised to remove all unnecessary furniture in the living areas. Other non-optical interventions she liked were a signature guide for banking, and extra illumination for near work. areas of significant visual loss within the central 20° of the visual field (the area of the retina providing fine detail). The person is tested while wearing their reading glasses or bifocals, if appropriate.
For perimetry, e.g. Humphrey perimetry, a new hand-held perimeter is available from the Low Vision Resource Centre (see page 13). It is quick to use and provides reliable and repeatable results.
Visual fields: tips for daily activities For people with central visual field loss: 1 Provide high magnification 2 Show them how to use eccentric viewing (see panel below).
For peripheral visual field loss, the best advice is to keep pathways clear and to avoid moving furniture in the house. A cane for walking around outside may be very useful.

Colour vision
It is rare for a person to be completely colour-blind, but reduced colour vision occurs more often in people with low vision. This can be assessed by asking questions such as: do you have difficulty when trying to find clothes of matching or similar colours? Have you noticed any problems when discriminating shades of colours? There are formal methods for colour vision testing, such as Ishihara plates and the Farnsworth dichotomous test (D-15), which involves colour arrangement. In practice, it is usually sufficient to see whether the person can see or match the primary colours, e.g. red, green, and blue. This can be tested using pencils or pieces of coloured fabric, for example, and asking the person what colour they see.
However, clinical colour vision testing can be valuable to make the correct diagnosis concerning the cause of a person's decreased vision.
Colour: tips for daily activities People with a colour vision deficiency or with blurred vision may find it difficult to distinguish between two colours that are similar. Suggest the following: • Arrange the food cupboard so tins or foods of contrasting colours are next to each other • Ask someone to help label clothes or to put matching outfits together ahead of time (on the same hanger/shelf) • Use other senses (touch and smell) to find out which fruit are ripe.

Magnification needed
Many people with low vision can benefit from magnification: using lenses to make objects appear bigger. However, magnification has its limitations. It is important to understand these limitations and explain them to the people you are helping so they have realistic expectations about what is possible.
• Stronger magnifiers have smaller lenses. You cannot have a strong magnifier that has a big lens! • Stronger magnifiers have more distortion around the edge of the lens, which means you can see clearly through the centre of the lens only.
So, although the object or word looks bigger, only a few letters or a small part of the object can be seen at any one time (see Figure 4). This reduces reading or working speed. Therefore, we recommend you prescribe the lowest possible power of magnifier that can be used comfortably for a long time (if needed).
With electronic devices such as closedcircuit television cameras and electronic readers, the same limitations do not apply. However, these devices are a lot more expensive than lenses.
Remember: to maximise the benefit of magnifiers, it is important that people wear an up-to-date pair of distance correction spectacles when testing magnifiers and that they wear their reading spectacles with stand magnifiers. For suggestions on predicting the level of near magnification someone will require, see the article opposite.

designing a management plan
Develop a management plan based on all the information you have gathered about the person with low vision.
Ask yourself: what does the person need? This depends on their history, their physical capabilities, the nature of their residual vision, and what they want to do. You may suggest some or all of the following: • Optical low vision devices: for near or distance vision • Non-optical interventions, such as caps for glare, a reading stand to reduce fatigue, a reading guide, various lamps, filters, sunglasses, etc. See the 'tips' given on pages 7 and 8; the case studies also contain useful ideas. • Environmental modifications, such as painting lines on stairs or using contrasting colours around the home (see page 12 and the case studies in this article).
Think about when the person should come back to see you again. Make an appointment if possible. This is also the point during the low vision assessment where you consider what other support the person will need, for example, educational support and/or visual rehabilitation and mobility training.
Write the necessary letters or notes and ensure the person knows where to go.
If possible, follow up with the referral service to check whether your patient has taken up the referral. If not, why not?

ManaGInG LOW VISIOn Continued
It is likely that people with loss of central vision (often associated with macular degeneration) will need to develop an eccentric viewing technique, in which they use their peripheral vision instead of their central vision. They might find it easier to see things if they do not look directly at them, but rather to one side or the other.
Eccentric viewing can be difficult to teach, and to learn. However, you could start by encouraging the person to try finding the best area for viewing for themselves, starting with real objects, then faces, and later on with larger letters or words. The person will eventually learn to control their eye movements.
If you have internet access, you can visit http://www.mdsupport.org/ evtraining.html for a guided introduction in how to use eccentric viewing.

Continues on page 12
Janet Silver Janet Silver How to predict the near magnification needed It is possible to use a simple formula to predict the amount of near magnification a person might need. The actual amount of magnification needed will vary according to the person's visual needs, environment, and the low vision device chosen. However, this is a useful starting point when selecting low vision devices to try out.
In this article, we use the testing distance of 25 cm, rather than the usual 40 cm, for two reasons: 1 Bringing objects closer makes them easier to see and improves contrast, important for people with low vision. 2 If we know the magnification needed at 25 cm, it is easy to calculate the dioptres needed to provide this.

Finding the magnification needed for reading
The formula we use is given below. It lets us predict the amount of magnification the person will need (2x, 6x, etc.).
Step 1. Find the near acuity achieved at 25 cm • Make sure the person is wearing their distance prescription, if any • Use a reading chart with sentences. Ask them to hold the chart at 25 cm • If needed, particularly in older people, add positive lenses (from +1DS to +4DS) to both eyes, to enable them to accommodate at 25 cm • Ask the person to read aloud • The smallest size the person can read with comfort and good speed gives their near acuity at 25 cm (Note: this is not the smallest size they can see!) • Write down the near acuity achieved at 25 cm, whether in M or N notation.
Note: M sizes differ depending on the testing distance used. Table 1 shows the M sizes of different types of text at both 25 cm and 40 cm. The latter is more familiar to most people. For our purposes, it doesn't matter which you use, provided you use the same notation throughout.
Step 2. Find the required near acuity at 25 cm • Ask what they want to be able to read • Determine the text size and record the required near acuity at 25 cm, in the same notation.
Note: Don't aim to record the smallest size a person can see. Recording the size the person can read with comfort and speed in Step 2 ensures that you will be able to choose the right amount of magnification.
Step 3. Use the formula to calculate the magnification needed • Divide the near acuity achieved at 25 cm by the required near acuity at 25 cm. This gives the amount of magnification required. For example: near acuity achieved is 2M, required near acuity is 1M: 2x magnification is needed to achieve this • Now that we know the magnification needed, we can calculate which dioptre lenses can provide this level of magnification at 25 cm.
dioptres at 25 cm = magnification x 4 • So to provide 2x magnification at 25 cm (see example above), a device of 8 dioptres (D) is needed: 2 x 4 = 8D • If you do not know the dioptres, check if the box of the device gives the 'x' (e.g., 2x) magnification. This is often given for a reference distance of 25 cm, which is the same distance used in this section.

Magnification for tasks other than reading
Magnification is useful for many other tasks, not just reading. For example, sewing, sorting seeds, and drawing. For people who cannot read, test their near vision using an E chart and record the size they can very easily see at 25 cm (Step 1). It is much easier to see the directions of just five 'E' letters than it is to read sentences, so the tester must resist the temptation to ask the client to read smaller and smaller sizes. Stop early! Estimate a size of text equivalent to the level of detail they would require for their activity (Step 2). You can now predict the near magnification required (Step 3).
Use the actual activity they want to perform to try out the different magnifying devices, so keep sewing thread and needles, or seeds for sorting, etc., in the clinic; or ask the person to bring their materials. Advise them on different ways of holding their work and the magnifier, and give advice on lighting. If they need two hands free for their activity, spectacle magnifiers are the best device to use.

Selecting a low vision device
Start by thinking about the following: • The person's visual abilities: can both eyes be used? Think about refractive error, ability to accommodate, and age • The task the person wants to do: can one or both hands be free? • The time for the task: short (such as checking a medicine label) or long (reading a story)? For a short task, a hand-held magnifier is fine, but for long periods of reading, dome, stand, or spectacle magnifiers would be better • The physical condition of the person. If the person's hands tremble, a hand-held magnifier is not useful and a spectacle magnifier would be better.
Other considerations include: • He is a lecturer at the Asmara College of Health Sciences in Eritrea and is the only person providing low vision services in that country.
The first time I tried to drive a car, my dad was sitting beside me, expecting me to do it right the first time. When I struggled, I was extremely disappointed and felt I would never drive again.
It is the same when people with low vision try to use a device for the first time. We, as low vision practitioners, may expect them to know how to use the low vision devices perfectly, without giving them any encouragement or training. We think that, as long as the person has achieved his or her desired vision in the clinic, our job is done. Far from it! Using low vision devices involves the development of completely new skills, often involving complex hand-eye coordination. And this requires practice. What seems natural and easy to us, such as focusing a telescope, feels quite unnatural to a patient the first time. The only way to solve this problem is to support and encourage our patients continuously.
Here are some basic steps: 1 Always explain to patients that it is fine if they are unable to perform the task the first time. Emphasise that this is normal.
2 Try to explain that there are things they can and cannot do as a result of their decreased vision, even with the help of the low vision devices. If that is not made clear, patients will have unrealistic expectations and will be disappointed with the resultswhich means they may give up learning how to use the device. 3 Give clear and step-by-step instructions. People with low vision usually respond well to verbal instructions. You can also give written instructions if the person or a family member is literate. Use good contrast and bigger letters where possible. 4 Provide regular, routine training. Teach your patients new skills only after they have mastered the previous ones. Giving too much information at once will make your patients feel stressed. 5 Follow up your patients. Everyone loves to be cared for. Encourage them and praise them when they have done well. Try to build their confidence and listen to their challenges. Sometimes it is better to listen than to talk. 6 Help them to solve their challenges one at a time. Sometimes meeting someone else with low vision can show patients that it is possible to overcome their problems.
Whenever my patients come back with a problem, providing support and encouragement is always the best way I can help them.
How to train people to use low vision devices 'Follow up your patients. Everyone loves to be cared for' a reading guide or reading slit helps to improve contrast, and it may reduce the amount of magnification needed.
low vision device; learning one device successfully builds the person's confidence and they will be more likely to come back for further support. Depending on the task the person wants to do, demonstrate one or more Iow vision devices that will provide the magnification they need. Allow them time to try the devices for themselves to see which work best.
Where possible, let them do something similar to what they would like to do at home, work, or school. Check the ease with which they are able to use the different devices and suggest modifications as needed. For example: add a reading guide, provide a reading stand, or increase available light.
Adapting the magnification to fit the person The magnification you predict a person will need (see page 9) is merely a starting point. Consider increasing the magnification by the smallest step possible for the following factors: • Poor light: if there is no electricity or the light is dim and cannot be improved • Tasks done for a longer time, such as reading or studying • Poor contrast, such as bills or other printed matter with poor contrast • A longer working distance needed, for example, if the person is physically unable to hold reading materials closer.
Demonstrate one or more devices that will provide the magnification the person needs to do their chosen tasks, and let them choose which one works best. It is important to listen to the person: what is comfortable for them? What can they physically manage? There is no point in giving someone a magnifier which they don't enjoy using.

With thanks to Tanuja Britto (ophthalmologist) and Anitha Jayan (rehabilitation professional), Joseph Eye Hospital, Tiruchirapally, India
Good patient flow • The unit should be laid out in such a way that it is easy for patients to go from one part of the unit to another • Some hospitals paint coloured lines on the floor which patients can follow. For example, a brightly coloured line may lead straight from registration to the first waiting area • Remove obstacles that people with low vision may fall over or collide with.
Use of colour, contrast, and lighting • Use large, clear letters for all the signs in the department. Ensure there is good overall illumination and avoid creating glare, which could be caused by using shiny white tiles on the floor and walls. For signs, use colours with high contrast, e.g., white or yellow lettering on a black or dark background Before you make any changes, make sure people with low vision can read the signs! • In the waiting area, use brightly coloured chairs, or paint them in a contrasting colour compared to the walls and floor. This will help people with low vision to find them and see the ones that are empty • Use tape or paint to apply a thick line to the edges of steps to make them more visible. Use ramps with a handrail instead of stairs, if possible • White hand basins and toilets against white tiles can make bathrooms very difficult to use. Change the colour of the walls and/or floor to improve contrast • If there are lifts, put a brightly coloured arrow or ring around the call button, or paint the door a different colour (Figure 2).
Staff assisting someone with low vision • Be patient: people with low vision may have visited many eye units or professionals already, and have told their stories many times before • Be kind: people may initially be angry when they are told they have untreatable visual loss. Listen and be supportive, but do not give false hope.
There are many things you can suggest that will help people with low vision make the most of their vision, whether they are able to benefit from magnification devices or not. If you are working at the community or at primary level, remember that these environmental modifications should never be a substitute for referral: always refer someone with low vison for an eye examination, refraction and low vision services wherever possible. If you are working at district/secondary or tertiary level, refer your patient for vision rehabilitation.
The suggestions given here are a good starting point, but some people may require further support and training in order to make the most of their vision.
A way of remembering environmental modifications is to think about: • Making things bigger and bolder • Using colour and contrast • Improving lighting, using lines, and trying to lift what you want to look at.

Bigger and bolder
Bringing things closer to our eyes makes them appear bigger. This mainly helps young people and children who have very good accommodation. People (including children) who have had cataract surgery and those with presbyopia will need a near add (a plus lens) to bring things into focus if they bring them nearer.
Use charcoal or a felt pen to write bolder messages, and write with larger letters than usual (Figure 1). Keep it short and simple! Put it somewhere visible and write on a bright piece of paper if you want to attract the person's attention.
Enlarging photocopiers and computer screens are also ways that print and other images can be made bigger and hence easier for the person with low vision to see.

Colour and contrast
Colour can be used in many ways to help someone in their home. For example: • Use brightly coloured plates (Figure 2) • Put red tape around light switches • Use paint or red nail varnish to put spots of red to help the person line up the "off" buttons on the gas cooker • Stand the person's shoes on a brightly coloured mat to distinguish them from   other family members' shoes • Mark the bottle of medication that is to be taken in the morning with a big yellow circle (to represent sunrise) and the evening bottle with a big black circle (to represent night).
Contrast makes things easier to see. For example, a black pen on white paper is easier to read than pencil. White writing on a black background gives the greatest contrast and hence is easier to read, but this can usually only be generated on a computer screen (Figure 3).

Lighting, lines, and lift
lighting is perhaps the best way to improve contrast, so if someone wants to read make sure the page is well lit. Ideally, the light should shine directly onto the page, but without producing glare. It should not shine in their eyes. Good lighting in darker areas of the home is important, particularly where the person may be nervous, e.g., going up and down stairs or going to an outside latrine.
At meal times, people with low vision can sit near the window or doorway so they can see what they are eating and when they have finished.
lines. Many people with low vision find it hard to follow a row of text: they may not be able to scan the words easily, they may find it hard to know when they have got to the end of a row of text, or they may struggle to find the beginning of the next line. Partly blanking out the lines above and below the line being read, for example, using a reading slit (see page 10), makes the visible line of print easier to read. A reading slit can be made of black card with a rectangle cut out of it.
Lines can help with mobility and safety. For example, paint the edge of stairs in a contrasting colour, or put white paint on the top of stones which mark the path to a neighbour's home.
lift. Figure 4 shows a locally made, foldable reading stand, lifts the page closer to the eyes and makes reading less tiring, particularly if magnifiers are used.

Useful resources for low vision
We know that, in many low-and middleincome countries, low vision services are limited to tertiary or teaching hospitals, which means that most people are not able to access them.
If this is the case, who can those with low vision turn to for help?
People with low vision do not fit comfortably within the job descriptions of most health and education professionals.
• They are not blind, so rehabilitation workers may not feel able to help them • Clinicians (ophthalmologists, ophthalmic nurses, and other mid-level personnel) feel there is nothing more they can do • Optometrists and refractionists can improve their vision, but cannot help them to see 'normally' • Special education teachers are usually trained just to work with children who are blind, and may not have the additional training needed to help children use low vision devices and advise them about where to sit and the importance of using their vision.
In fact, the services of all of these people are vital to ensure that the person with low vision can live a full life.
One of the most important things we can do, whatever our own role, is to be aware of what other services may help the person with low vision and refer them. And we must communicate with the person, the family, and our colleagues in these other services about the care the person needs, in clear and simple language.

Importance of referral
People with low vision may need clinical care, refraction, and rehabilitation support, and children and others in full-time education will also require educational support. We may be the first point of contact for the person with low vision, or their last hope for help. Whatever the case, it is our responsibility to find out whether the people who come to us have received clinical and refractive error care. If they have not, it is essential that we refer them. If they have, we must find out what other support they might need and refer them. But it is not enough to just refer -it is also our responsibility to make contact with our colleagues in local community rehabilitation and educational support services. Refer people as appropriate, and share information with these colleagues about any changes in the The Low Vision Working Group of VISION 2020 has endorsed a Standard List for low vision services. 1 However, it may not always be possible to purchase all the items on the Standard List.
We have put together a list of the minimum equipment and devices you would need to offer a basic low vision service at district level. This list is based on our experience in the field, and we hope it will help you to start providing low vision support where no other service is available.
Keep accurate records of who you see and how they have been helped. Collect quotes from patients saying how they have benefited, and use these and your records to ask for further training, increased funding, and better equipment for your low vision clinic. Always refer people with complex needs for services at a higher level. Optical low vision devices • Spectacle magnifiers: locally made high positive add spectacles, from +4D to +12D, in steps of 2D.

Ophthalmic equipment
• Four hand-held magnifiers (nonilluminated) from 5D to 20D. For example, one of 6D, one of 10D, one of 15D, and one of 20D • Non-illuminated stand magnifiers from 10D to 25D. For example, one of 12D, one of 16D, one of 24D

Secondary or district level
At secondary or district level, services are aimed mainly at adults and older children who want to access print or perform tasks that require good near vision. The panel on page 14 lists the minimum equipment you will need to start a low vision service at secondary or district level. At this level, optometrists and mid-level eye care workers can be trained to give basic low vision services appropriate to their skills and experience.
They should have good communication skills and be able to do the following: • Test distance and near visual acuity (ideally also in younger children) • Perform objective and subjective refraction • Perform minimum essential low vision assessments (page 4 onwards) • Prescribe essential low to medium magnification devices for near and distance, with training in their use (pages 9-10) • Advise patients on non-optical interventions and environmental modifications (page 12) • Refer people to the most appropriate person or organisation for further training, financial help, and education • Refer young children and those with complex needs to the tertiary level • Ensure regular follow-up of adults and children who were seen at tertiary level.
tertiary level or teaching hospital Well-trained, dedicated low vision staff can provide the following: • Complex assessment tests • Refraction of people with complex problems • Provision of a wide range of devices, including electronic devices • Good links to education and rehabilitation services • Training the use of low vision devices.

Beyond the clinic
There will be many more people with low vision in the community who need our services.
Think about how you can reach out to tell them about what you offer. Plan outreach clinics, or link with others working in the community.
Visit schools for the blind -perhaps there are children who will be able to use their remaining vision if they receive low vision support.
Low vision work may be challenging, but it is immensely rewarding! Our recent survey 1,2 found that low vision services were often inaccessible to large numbers of people in low-and middleincome countries.
Based on the findings of this research, we suggest three areas for action: human resources, sustainability of services, and advocacy. However, it is important to keep in mind that these strategies must be adapted to suit your situation.

Human resources
• Integrate low vision into existing ophthalmic and optometric curricula and include it in the practical training of education and rehabilitation workers • Offer informal low vision workshops and courses for eye care workers who have not received formal training. • Delegate tasks to less specialised health workers where possible. For instance, instead of the optometrist doing the simple refraction and basic low vision care, a trained vision technician could do these tasks. • Build on the skills of existing staff. For example, in areas where there are no ophthalmologists or optometrists, refractionists, ophthalmic nurses, and opticians can be trained to take on additional low vision tasks appropriate to their skills and experience.

Sustainability
Strengthen community-based rehabilitation and outreach services.
• During outreach, you could explain or show how the home environment can be adapted and make timely referrals to district level care. Through outreach, people can be followed up to ensure they are still able to use their low vision devices, and you can give refresher lessons to those who need it. In addition, children with poor vision can be detected and supported early. • Outreach services should be carried out on a regular basis, although the frequency may vary, depending on need. • Integrate low vision services into existing education, rehabilitation, and eye care systems. Establish appropriate and healthy collaborations between the government and the private sector.
• Non-governmental organisations must work together with the private sector and government to support and fund low vision services. However, for this to work in the long term, the government must take the lead and take ownership of programmes and services.
advocacy We recommend two strategies: 1 Use strong research evidence on which to formulate policy. 2 Encourage NGOs and all stakeholders with an interest in low vision to come together under one umbrella organisation, i.e. a national VISION 2020 or prevention of blindness committee. The group can then deliver the policy message with one clear voice.
Once advocacy and lobbying have started, more detailed planning must be done at the implementation level. For instance, encourage local government and policy makers to include low vision in their district VISION 2020 or eye care plans. Improving the flow of patients through our eye programme is about making their journey easier while making the best use of our own time and resources in the eye clinic. It involves elminating unnecessary steps and processes, giving us more time to focus on our patients and on providing a good -and friendlyservice. Eye care administrators and managers benefit too: better patient flow reduces waste and makes more efficient use of theatre time and human resources, which in turn reduces costs, attracts more patients, and improves cost recovery.
Thinking about what our patients value can help us to optimise patient flow. Generally speaking, patients value everything that provides them with a good outcome: appropriate referral, a correct diagnosis, the right information and advice, the right treatment, and appropriate follow-up and aftercare. They do not value things that seem unnecessary to them, for example: waiting longer than seems reasonable, having to provide the same information more than once, or travelling to the hospital more than once when two visits can be safely combined.
It is therefore very helpful to look at our eye service as a whole from time to time, particularly if we have received negative feedback from our patients. We must examine everything we do: from the moment of first contact with our patients to the time they are finally discharged after a successful follow-up examination.
The good news is that, by thinking about our patients and how to provide them with a good experience in our clinic, we will be able to make changes that benefit the the clinic as well. See Table 1 for some examples.
the patient journey It helps to consider the patient's visit to the eye clinic as a journey. Here are some examples of the different 'stations' along a patient journey through an eye clinic: •Registration •Retrieval of medical records •Visual acuity testing •Slit lamp examination •Consultation •Treatment •Fee collection If we want to consider how a patient is referred to our clinic, particularly if our clinic forms part of a VISION 2020 district programme or a government district health care system, we can include steps such as 'outreach', 'primary health care referral' and so on in the list above.

Understanding existing patient flow
Many patients will travel through our eye clinics and it is our responsibility see that patient flow is well managed. Before making any improvements, start by assessing (or auditing) the existing patient flow in the eye clinic. This can be done by one person, but it is often better to invite representatives from both clinical and support staff to help. Everyone's input is valuable.
Regular evaluation of patient flow will allow us to identify problems and make helpful changes. The suggestions that follow overleaf should help you to start thinking about patient flow and identify areas for improvement.
The focus should be on what patients value: does the way the clinic function help us to give patients the best service we can?
•List the different 'stations' on a typical patient's journey through your clinic. How long do they have to wait before

access
• A total of 57% of respondents had internet access whenever needed, but around half cited slow speeds, high costs, and lack of know-how as reasons for preferring not to read the journal online. In another part of the survey, respondents described using the paper copy as a teaching aid when educating patients or training students. • Nearly two thirds of respondents had access to a computer, and 79% had found the Community Eye Health Update CD 'useful' or 'very useful'.

Impact
• 91% of respondents said they used the journal to teach or educate others, including patients and the community. • 90% of respondents agreed that the journal had improved and/or supported their work.
• 80% said that something they read in the journal had led them to change their clinical practice or management of patients. • The vast majority of respondents (89%) worked directly with patients; they had contact with an average of 60-79 patients per week. • 80% agreed that the journal had motivated them to reach out to the community, 75% that it had changed the way they conducted health education, and 70% agreed that it had changed the way they talked to patients, stimulated them to talk to non-eye care colleagues, and motivated them to stay in eye care. • Respondents passed on the journal to an average of ten other readers each.
We are encouraged by the positive response to the journal and appreciate the many helpful suggestions for future themes we received.
With thanks to Prof Allen Foster, Prof Clare Gilbertl, Anita Shah, Sally Parsley, and George TH Ellison DSc.

Knowing what to change
There are various approaches to analysing patient flow, with names like 'process mapping' and 'value stream mapping' (see 'Further reading' on page 35). Finding and eliminating bottlenecks is another approach and is relatively straightforward. The aim is to reduce waiting times and make better use of equipment and the time of clinicians.
Bottlenecks are usually easy to identify: they are the areas with the longest queues! For example, one often sees long queues in front of the visual acuity testing station, whereas, in another part of the clinic, the screening station is waiting for patients. In this instance, the visual acuity testing station is the bottleneck -it is the part of the clinic where patients are getting stuck.
Using an additional person at the visual acuity testing stage would speed up the flow of patients through this area and provide a steady stream of patients at the screening station. Patients will therefore have a quicker journey, and eye care workers' time will be used more efficiently.
It is worth noting that this is a process of ongoing improvement: once one bottleneck has been dealt with, it will very soon become clear if another part of the clinic has become congested and will require attention.

How to make changes
Once we better understand patient flow in our eye clinic, and where the delays and inefficiencies are, the next step is to talk to clinical and support staff about how improvements can be made.
It is important to create an atmosphere of teamwork and collaboration, and to encourage everyone to contribute their ideas. Janitors or stock control clerks, for example, may offer valuable insights into everyday processes that can be streamlined.
Giving staff an opportunity to contribute has the added advantage of making staff members feel like part of a team; agreeing on a shared goal also makes it easier for people to work together.

Practical suggestions
Becoming better organised allows us to make better use of available clinic space and infrastructure and to make better use of staff time.
This can often avoid or delay the need for an expensive expansion programme! Here are some practical ideas for improving patient flow.
Better systems • Standardise procedures in the clinic.
This will allow more patients to be seen in a day and make it easier to keep quality consistent. • Use tags or stickers on charts to make them easy to identify. • Make use of helpful technology where appropriate. For example, use computers for indexing records or use devices that will speed up intraocular pressure readings. • Some days are busier than others (e.g., Mondays are usually busier because of weekend emergencies). Part of a solution to an overcrowded clinic may involve moving clinic activities to different days to allow a better spread of patients throughout the week. • To reduce unnecessary back and forth movement of patients because of multiple payments to cashiers, try to offer 'package' prices that cover the cost

OrGanISInG EyE SErVICES Continued
The team responsible for leading the changes at KCMC used a baseline assessment form produced by Lions Aravind Institute for Community Ophthalmology to help them understand the eye department's resources and problems. Problem areas included: •Inconvenience for patients: the system for a patient to be registered for outpatients or admission was lengthy and complicated. •Personnel used inefficiently: many nurses spent more time on clerical duties than on nursing, and doctors were often responsible for mundane management tasks. •Inefficient procedures: there were no standard clinical protocols for common problems like cataract. •Monitoring: basic annual patient service statistics were collected, but these were not discussed with staff. •Stores and purchasing: there was no system for making stores reports and none were made; there was no system for efficient purchasing. • of multiple services. Or set up a system that allows patients to pay when they leave for all the services they have used. • Good internal communication systems (intercoms, or an intranet) between the various departments will make it easier to share information about patients and will also save time (see panel on right for an example from Madagascar). Better use of staff • Make good use of mid-level ophthalmic personnel, nurses, and nursing assistants. They are usually highly trained and can perform many tasks that will free up the time of ophthalmologists so they can focus on what only they can do. • Make more staff available during busy times, and stagger lunch breaks so that work flow is continuous. This will reduce patients' waiting times. • Encouraging a culture of teamwork will help to improve patients' experience at the clinic. Treating staff fairly and with respect will reduce the likelihood of interpersonal problems.

Doing a baseline assessment
• Problems in how staff are managed can lead to poor team morale. Staff who are happy, and feel respected by their colleagues or managers, find it easier to be kind and friendly to patients and to contribute to clinic improvements.
Other problems that affect patient flow There are some problems that affect the entire patient journey.
• Inefficient recordkeeping can cause many delays. A records retrieval rate of less than 90% should not be tolerated in an eye clinic! Periodic review of all forms and stationery is useful; check that patients do not have to provide the same information more than once, unless absolutely necessary. • Patients and clinic staff who do not understand each other's language is another common problem. Take steps to ensure that essential patient education materials are available in a local language, particularly instructions for medication. Where possible, ensure there are sufficient interpreters available. Ask for help from local churches or community organisations.

an ongoing journey
A patient's journey does not end when she or he leaves our clinic. Good referral to other services, such as low vision or rehabilitation clinics, must form part of the service you offer. The spacing of follow-up visits should also reflect the patient's situation and balance the need for good clinical care with the ability of patients to travel to the clinic. Clearly indicate the date of any follow-up visits on the patient's records, and send reminder messages by cellphone (mobile phone) if possible.
Optimising patient flow is a journey of ongoing improvement. We hope that this article has helped you take the first steps.
SALFA Eye Clinic in Fianarantsoa, Madagascar, has introduced a fully integrated electronic medical records system recently. All major stations (reception, pharmacy, cashier, ophthalmologists, manager, stores, etc.) have a computer terminal, headset and webcam. This allows for quicker and cheaper communication: staff can talk to and see each other free of charge using Skype, a free software package that requires internet access in order to work (www.skype.com).
The records system also gives the clinic manager, Somoela Rajaona, all the information he needs to manage patient flow. For example, he can see how many patients are waiting to be seen by the doctor, the stock situation, and so on.

an IntEGratEd InFOrMatIOn and COMMUnICatIOn SyStEM
Once the new community outreach programme started bringing in large numbers of patients, especially late in the day, the need to make ward and theatre procedures more efficient became critical. The team decided that it would be more efficient if the counsellor (a trained nurse) working in the outreach programme recorded vital signs, completed consent forms, and educated the patients right there in the field. As a result, the ward nurses had less to do at the time of admission. New forms, designed by an external nurse consultant working with the eye department nurses, also saved time.
In the operating theatre (OT), improving efficiency was partly a matter of clearing unnecessary equipment and supplies from the OT so that an extra operating table could be installed. It also required many discussions with the doctors as to how the OT should be run and the importance of starting on time.
Under the leadership of the nursing co-ordinator, and motivated by positive feedback and praise from the head of the ophthalmology deparment, more nurses began to take pride in their accomplishments; this was a modest but important step forward in achieving better attitudes and motivation. Educational role of the newspapers should be better tapped. Making the information interesting is the key word," mr n ram, Editor, the Hindu.

Improvements on the ward and in theatre
"There is a need to go to the ground level to understand the situation and then write out the key messages. Sitting in the air-conditioned offices will not help us write effective messages," mr S K Kulkarni, advisor, Kesari newspaper.
"Be accurate, consistent and don't compromise ever on facts but at the same time there is nothing wrong make your story more presentable," mr arun ram, Senior Editor, times of india, Chennai " Target the vernacular press to reach out to the masses", ms aarti dhar, Senior assistant Editor, the Hindu, delhi.
These were some of the key messages made by journalists participating in a oneday national workshop on 'Media and its role in eliminating avoidable blindness' organised by VISION 2020: The Right to Sight -India held at Sankara Nethralaya, Chennai, India on December 10, 2012. The aim of the workshop was to sensitise the media on issues of eye care and also invite inputs from them on how VISION 2020: The Right to Sight -India and its members can communicate effectively through the media to reach out to the community. " Media can be a powerful tool not only to deliver eye care messages to the community for better uptake of services but also as an advocacy tool to influence the policy makers," said Dr GV Rao, CEO, VISION 2020: The Right to Sight -India regarding the mandate of the workshop.
The workshop was inaugurated by Col (Retd) Dr Deshpande, President, VISION 2020: The Right to Sight -India who welcomed the audience, senior ophthalmologists and journalists defining the need for such a workshop. He said that the country had a huge backlog of eye related cases and now there were new eye problems emerging that had to be treated. And in tackling this huge problem, "We require media's help to reach out to the general public to create awareness so that the uptake of eye care services provided increases." An overview about blindness scenario in India; Challenges for Managing Eye Care Programs; Media's role in creating awareness and Mainstream media and beyond for creating awareness were the four sessions of the workshop. Senior ophthalmologists and head of eye hospitals presented all aspects of eye care -right from the burden to the barriers to the role of tertiary, the need for advocacy and how media can help NGOs working in eye care in creating awareness towards sensitising the media regarding the eye care scenario in India.
Dr The one common message threaded the presentations of all the media persons was that the communication that is given for publishing should be interesting, saleable, news worthy, simple and to target the vernacular papers.
Participating in the panel discussion for the media, which was conducted by Col (retd) Dr Deshpande, eminent journalist Mr N Ram emphasised the increasing reach of the language newspaper in India. He said the educational role of the newspapers should be better tapped. However what is of utmost importance is making information interesting and that is the key word: "Educative of course, but making it interesting is most important." Mr Arun Ram from the Time of India also held a similar opinion. He rejected the common view that those who can pay get more coverage. According to him what was of importance was that news should be saleable. "I feel every story has to be presented well." Mr Arun, who has reported on health issues wanted eye care NGOs and hospitals to look into why certain health news is not carried? "Heart gets a lot of coverage. The basic reason may be that a lot of people are afraid of getting a heart attack and not about going blind." All the media persons on the panel were unanimous that if the aim is to reach to the masses, especially in small towns and villages, it is best done through the vernacular news paper: be it print or electronic.
Mr SK Kulkarni who has travelled far and wide in the country and has been very proactive in promoting development sector news agreed that "if we have to reach out to the masses in the villages, we have to go with the language newspaper. It has to be in a language that is understood by them." Ms Aarti Dhar of The Hindu who has been reporting on health issues for a decade now was also of the same opinion, "As far as English versus vernacular papers are concerned, English papers like The Hindu or NDTV may be effective, if one wants to influence the policy makers, but when it comes to the masses, it is best to approach through the vernacular press." Dr Neeraja Prabhakar, Programme Executive, All India Radio (AIR), Chennai emphasised the importance and reach of the community radio which is generally not known. She said, "The mandate of community radio is to broadcast programmes on health, environment etc should be tapped." She suggested that eye care NGOs could explore the possibility of collaborating with AIR where news on where eye camps are being held can be disseminated.
The media persons who had been listening to presentations made on eye issues requested the eye care fraternity to keep the messages simple and also shared challenges faced by them while reporting.
One of the challenges faced by reporters covering development news is the low priority given to such news. A phenomenon that is global in nature. Political developments, business news get priority over other news in the Indian scenario. Faced with a space crunch in the newspaper, the first casualty is development news which is put on hold and eventually dies a natural death.
Ms Aarti was candid in sharing that all the presentations made during the workshop to sensitise them were full of facts and were too technical. "We have to understand the facts first and then present it in a manner that can be understood by the layperson who does not know what glaucoma or retinoplasty is. I have to report it in such a basic level which my maid will understand, my mother and my grandmother will understand." "It does not mean that the facts have to be taken off. It is only to say that the story has to be more presentable. If we are talking about stories on blindness then a visual story is any day more effective than a 200 words story in the print media," suggested Mr Arun.
Mr Kulkarni came out with an action plan and suggested that NGOs could have a panel of writers, maybe journalist, who could write popular language about eye care messages. "We have to go to the ground level to understand and then write out the messages. Sitting in the air condi-tioned offices will not help in writing effective messages." Senior media persons, Mr Ram and Mr Kulkarni who both have the experience of heading newspapers had some suggestions to encourage media coverage. Mr Ram took the example of MS Swaminathan Research Foundation who have held regular workshops on genetics to sensitise the media. The result may not be immediate but in the long run this strategy does help.
Mr Kulkarni suggested a fellowship where journalist can be assigned to study a particular problem in a particular area. This will take care of creating awareness in remote areas like the north east and most important that writing well is the key.
On damage control reporting and about negative reporting, Mr Ram said that in event of accident/infection, the organisation should reach the media with their story first before the news is distorted and published. He also urged that such workshops be held different regions.
The way forward for VISION 2020: The Right to Sight -India is now to analyse the inputs from the media, prepare a guideline on how in approach and how effectively to utilise them to reach to our target audience. Vision 2020 India Newsletter

Past Events
World Sight Day (WSD) an international day of awareness, held annually on the second Thursday of October to focus attention on the global issue of avoidable blindness and visual impairment is observed by a majority of eye care organisations across the globe. In India, VISION 2020: The Right to Sight -India and its member organisations observed the World Sight Day with a number of events ranging from walkathon, painting exhibition by school children, a cultural programme by the visually challenged children, exhibition, a huge visually acuity chart and many more innovative events nationwide based on this year's theme 'Eye Testing for All'. All towards draw attention towards the need for a regular eye check up. VISION 2020: The Right to Sight -India held programmes over two days -October 10 & 11, 2012: a technical session -'Glaucoma: an emerging eye care challenge in India' at Sankara Eye Hospital, Anand, Gujarat on October 10, 2012 emphasised on various aspects of glaucoma with a special emphasis on problems in Gujarat state, the venue of the session. Eminent ophthalmologist from across the country and from Gujarat through their presentations discussed what needs to be done to manage this emerging eye problem, which is the third leading cause of blindness in India. There was good participation from the government both from the Central and the State government departments of health and offered a platform to VISION 2020: The Right to Sight -India for advocacy. Banners and flags with messages on the need for a regular eye check up carried by enthusiastic children marching to the tune of popular songs played by a band marked the opening of events on October 11, 2012; the World Sight Day. The event was organised by Care Group, member of VISION 2020: The Right to Sight -India in Gujarat. The walkathon was flagged off by Ms Sujaya Krishnan, Joint Secretary, Ministry of Health and Family Welfare, Government of India and Mr Ashwini Kumar -I.A.S, Municipal Commissioner, Vadodara, Gujarat and saw participation from school children, ophthalmologists from the city who weaved their way through the busy road of Vadodara, Gujarat. Dr N K Agarwal, Dy Director General (Ophthal), National Programme for Control of Blindness, Government of India and Col (retd) Dr Deshpande, President, VISION 2020: The Right to Sight -India released multicoloured balloons to mark the occasion. School children held an exhibition creatively depicting various problems of eye care. The best six paintings from this exhibition will form part of the calendar for 2013. In a unique effort, Ms Elizabeth Kurian, Secretary, VISION 2020: The Right to Sight -India requested a couple of school children and the dignitaries for the event to blindfold themselves for a minute to experience how the visually challenged's world would feel. After a minute when the children removed the blindfold and were asked to share their experience, prompt came the reply "we cannot see the beauty of the nature." Ms Sujaya Krishnan, Joint Secretary, Ministry of Health and Family Welfare, Government of India addressed the children advising them to participate in the school screening programme. She also gave them tips on nutritive food to eat for healthy eyes . Dr NK Dr N K Agarwal, Deputy Director General (Ophthal), National Programme for Control of Blindness, Government of India spoke about the need for eye testing for all and how we can do the basic screening at home. Visually impaired school children gave hearth warming performance of popular songs from films and dance.

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Community EyE HEaltH Journal indian Edition | VolumE 2 iSSuE 4 School children marching at the walkathon. india The wSD walkathon being flagged off by senior government officials. INDIA Sridevi S Sridevi S